The new sheriff just turned the town upside down. Veterans Affairs’ new Secretary, Dr. David J. Shulkin, as expected moved quickly on the VA’s EHR modernization before the July 1 deadline, and moved to the same vendor that the Department of Defense (DoD) chose in 2015 for the Military Health System, Cerner. VA will adapt MHS GENESIS, based on Cerner Millenium. The rationale is seamless interoperability both with DoD and with private sector community providers and vendors, which base their services on commercial EHRs. The goal is to have one record for a service member through his or her lifetime and to eliminate the transition gap after discharge or retirement. (Transition gaps are also repeated when reservists or National Guard are called up for active duty then returned to their former status.) Another priority for VA is preventing the high rate of suicide among vulnerable veterans.

Updates:VA confirmed that Epic and Leidos will keep the development of the online medical appointment scheduling program, awarded in 2015 and currently in pilot, to be completed in 18 months. The contract is worth $624 million over five years. Wisconsin State Journal The House Appropriations subcommittee on Veterans Affairs likes the Cerner EHR change. The Senate Veterans Affairs Committee is meeting Wednesday to discuss the VA budget sans the EHR transition. The EHR numbers are expected to be sooner rather than later. POLITICO Morning eHealth

Dr. Shulkin is well acquainted with the extreme need for a modernized, interoperable system serving the Veterans Health Administration (VHA), having been on the US Senate Hot Grill for some years as Undersecretary of Health for VA. The foundation for the move from homegrown VistA to Cerner was laid last year during the prior Administration through an August RFI for a COTS (commercial off the shelf) EHR [TTA 12 Aug 16] and in later hearings. “Software development is not a core competency of VA” and it has been obvious in system breakdowns like scheduling, maintaining cybersecurity and the complex interoperability between two different systems. To move to Cerner immediately without a competition, which took DoD over two years, Dr. Shulkin used his authority to sign a “Determination and Findings” (D&F) which provides for a public health exception to the bidding process. The value of the Cerner contract will not be determined for several months.

For those sentimental about VistA, he acknowledged the pioneering role of the EHR back in the 1970s, but that calls for modernization started in 2000 with seven ‘blue ribbon’ commissions and innumerable Congressional hearings since. He understated the cost in the failed efforts on interoperability with DoD’s own AHLTA system, VA’s own effort at a new architecture, and modernizing the outpatient system. This Editor tallied these three alone at $3 billion in GAO’s reckoning [‘Pondering the Squandering’, TTA 27 July 13].

It is still going to take years to implement–no quick fixes in something this massive, despite the urgency.

Both MHS and VA will be running two systems at once for years

MHS GENESIS is currently testing at four MHS locations, which is speedy given the award was July 2015. A ‘go’ decision will not be until 2018, with completion of full rollout anticipated in 2022 (FedHealthIT). That rollout impacts 204,000 health professionals at 1,230 locations that serve 9.5 million patients in 16 countries.

Assuming there are no objections from Congress or other EHR vendors on the D&F to slow the process, if Cerner adheres to a similar timetable, the adaptation of the Millenium EHR to full rollout will take at least five years (trimming some time for DoD learnings). Currently, VA has over 1,700 sites of care, serving 8.76 million veterans. VA will be running a rapidly aging VistA along with developing and rolling out Cerner Millenium to 2022 or later. Who will be responsible for maintaining VistA over that time, if software isn’t a ‘core competency’ of VA?

VA has, as acknowledged, different services than the DoD MHS and a far broader age range to serve with many more chronic and specialized needs. These modifications will take time, resources, and staff.

There may be a lot of clinging to VistA in VA-land. An article in HIT Consultant written by an executive for Medsphere Systems, the solution provider for the OpenVista commercial system, points out that VA doctors and clinicians have generally liked VistA while MHS doctors disliked AHLTA. While even a casual read reveals the article’s bias, VA staff do not operate as the Army and Navy Medical Departments do within a formal chain of command. Can VA win over its own?

And whither the four VHA Home Telehealth providers? Over the five years of their contracts [TTA 6 Feb], they will have to develop interfaces from their systems designed to VA specifications into two EHRs: VistA and Cerner. For Medtronic, with an incumbent system into VistA and huge resources, including Cerner interoperability knowledge from other products, it is easy. For the other three–Intel Care Innovations, Iron Bow/Vivify Health, and 1Vision (with a partner still not formally announced)–it will be a strain. Suddenly the $258 million award over five years doesn’t look so generous anymore.

Our definitions

Telehealth and Telecare Aware posts pointers to a broad range of news items. Authors of those items often use terms 'telecare' and telehealth' in inventive and idiosyncratic ways. Telecare Aware's editors can generally live with that variation. However, when we use these terms we usually mean:

• Telecare: from simple personal alarms (AKA pendant/panic/medical/social alarms, PERS, and so on) through to smart homes that focus on alerts for risk including, for example: falls; smoke; changes in daily activity patterns and 'wandering'. Telecare may also be used to confirm that someone is safe and to prompt them to take medication. The alert generates an appropriate response to the situation allowing someone to live more independently and confidently in their own home for longer.

• Telehealth: as in remote vital signs monitoring. Vital signs of patients with long term conditions are measured daily by devices at home and the data sent to a monitoring centre for response by a nurse or doctor if they fall outside predetermined norms. Telehealth has been shown to replace routine trips for check-ups; to speed interventions when health deteriorates, and to reduce stress by educating patients about their condition.

Telecare Aware's editors concentrate on what we perceive to be significant events and technological and other developments in telecare and telehealth. We make no apology for being independent and opinionated or for trying to be interesting rather than comprehensive.